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Oral Tumors
TUMORS OF THE ORAL CAVITY Tumor: is simply a swelling or lump. Neoplasm: is a new growth of tissues in which the multiplications of cells is uncontrolled or progressive. Hypertrophy: is an increase in cell size without an increase in cell number. It may be physiological (normal response to increased demands of a tissue) or pathological (gum hypertrophy in epileptics). Hyperplasia: is the increase in cell number without an increase in cell size. Also it may be physiological (breast during lactation or hypercementosis) or pathological (denture fissuratum, prostate in elderly males).
I. Classification of oral tumors I- According to tissue of origin: a- Odontogenic These are neoplasms arising from cells of the odontogenic apparatus. 1. Epithelial origin e.g, ameloblastoma, enameloma. 2. Mesenchymal origin e.g, odontogenic myxoma, cementoma.
3.
odontome.
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b. Non-odontogenic These neoplasms may arise from surface or lining epithelium, or from various connective tissues. II. According to clinical behavior Benign tumors Slow growth Grow by expansion and pressure on the adjacent tissue. Usually has a fibrous capsule, and well separated from the surrounding tissues. Malignant tumors Rapid growth Grow by invasion and infiltration of the adjacent tissues. has no capsule and poorly demarcated from the surrounding tissues
Usually of large size. Usually of small size Never metastasize capsule and poorly Re c u r r e n c e i s ra r e Resemble the parent tissue (well differentiated) Show little cellular atypia and few mitosis No necrosis as no Commonly metastasize. Recurrence is often. Poor resemblance to the parent tissue (poorly differentiated) There is striking atypia and frequent mitosis Frequently . show central necrosis and invasive activity at the margins
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II. Examination and diagnosis of oral tumors I- History; this includes 1. Past and present medical history. 2. History of the lesion; which includes. a. Duration of the lesion. b. Change in size. c. Change in character. d. Symptoms associated with the lesion. II- Clinical examination
1. Size and shape of the lesion 2. The surface of the lesion: may be smooth, lobulated, irregular or ulcerated. It 3. The color of the lesion: e.g, bluish mass blanches on pressure may indicate
hemangioma.
4. The consistency of the lesionIt may be soft (lipoma), firm (fibroma), hard :
mass.
6. Presence of pulsation: Palpation of a mass may reveal a palsatile quality
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Location Size. Tenderness (painful versus non painful). Degree of fixation (movable, matted, fixed) Consistency (hard or firm).
In malignant lesion L.N become enlarged and fixed in position. Classifications of Lymph nodes: A- Local lymph nodes (Pre-cervical L.N): Inner ring: includes Palatine tonsils. Pharyngeal tonsils. Lingual tonsils. Outer ring: includes Submental L.N. Submandibular .L.N. Buccal L.N. Pre-auricular L.N. Post-auricular L.N. Occipital L.N B- Regional nodes (Cervical L.N):
Superficial cervical L.N: related to E.J.V. Deep cervical: related to I.J.V. 1. Upper deep cervical: jugulo-digastric L.N. 2. Lower deep cervical: jugulo-omohyoid L.N. Anterior cervical: Pre-laryngeal and Pre-tracheal. Supraclavicular L.N.
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ill defined borders with extensive bone destruction loss of lamina dura and widening of PDL space floating teeth in sarcomas, root resorption occurs invasion of maxillary sinus destruction of inferior alveolar canal cortex Plain radiograph: Indicate intra-bony lesions. C.T.: Indicate intra-bony lesions. M.R.I.: Indicate intra-bony lesions. Ultrasound Scintegraphy: denote distant metastasis. Sialography: assess S.G. tumors.
Biopsy is the removal of tissue from a living individual for Value of biopsy: 1.
2.
micropscopic diagnostic examination. Proper and correct diagnosis. Determination of the degree of malignancy e.g., by Determination of the prognosis.
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a. b. c.
Indications: Lesion not responds to ttt within 14 days. No apparent cause. If suspect malignancy. Types of biopsy: A) Excisional biopsy 1. It is the complete excision or removal of the lesion. 2. A margin of 2-3 mm of the surrounding normal tissues should be excised with the lesion to ensure its total removal.
3. Indications:
a.
b.
B) Incisional biopsy:
1.
It is the removal of a portion or sample from the edge of the lesion with Indications:
3.
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4. Principle
a.
which may cause distortion of the tissues. Ring block or regional nerve block is recommended. d. Also avoid cauterization, areas of necrosis and/or impaction of
foreign bodies.
e.
staining properties (iodine) because this will change the staining character of the tissues.
f.
For obtaining samples from deeply seated lesions. Indication: intra osseous lesion
2.
D. Punch biopsy
1.
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F. Curettage biopsy
1.
In this type, tissues removed from the depth of tooth socket after extraction
It is the most valuable investigation for cystic and fluctuant lesions. A wide bore needle (18 gauge) attached to a 10 ml syringe is used. The
needle is inserted deeply into the lesion for aspiration of its contents. 3.
The results of aspiration may be: Air indicating maxillary sinus or traumatic bone cyst. Pus indicates an abscess or infected cyst. Yellowish (creamy white) inspissated material resembling pus
without its unpleasant smell denotes the presence of keratocyst. Straw-colored fluid containing cholesterol crystals indicates
periodontal or dentigerous cysts. Blood indicates vascular tumor or aneurysmal bone cyst. Mucinous fluids indicate ranula or mucocele.
firmly by a spatula or tongue depressor. The cells obtained are smeared on a glass slide, fixed and stained, and microscopically examined. It is useful in poor surgical risk patients & in surface lesion when malignancy is suspected.
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disposable plastic syringes. The needle is inserted into the lesion and moved in and out and laterally in three dimensional planes without being removed outside the lesion.
2.
Cells from the lesion will be collected inside the lumen of the needle. Then
the needle is withdrawn and the aspirate containing the cells is disposed on a glass slides. It is then spread, fixed, stained and examined microscopically. 3. 4. 5. Indications: S.G & L.N. Adv.: simple, atraumatic & cheap. Disadv: insufficient sample.
J. Unplanned biopsy:
1.
K. Exploration biopsy: 1. 2. Surgical Exploration of internal lesion Indication: deep internal lesion
M. Brush cytology: 1. Special brush scraps the lesion 5-10 times to collect cells 2. Cells are fixed and stained on glass slide for microscopic examination 3. adv.: simple, quick & painless 4. Indications: suspicious superficial malignancy.
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1. ODONTOGENIC TUMORS These comprise those neoplasms that arise from any portion of the dental formative tissues. Classification of odontogenic tumors I . Epithelial Odontogenic Tumors
A. Benign 1. Soft tissue a. Simple Ameloblastoma. b. Calcifying Epithelial Odontogenic Tumor (Pindborg's Tumor). c. Squamous Odontogenic Tumor. 2. Hard tissue (with inductive changes) Enameloma (Enamel Pearl). 3. Mixed (with inductive changes) Adenomatoid Odontogenic Tumor. B. Malignant 1. Soft tissue a. Malignant Ameloblastoma. b. Ameloblastic Carcinoma (Carcinoma Ex Ameloblastoma). 2. Hard tissue (with inductive changes) No such lesion exists. 3. Mixed (with inductive changes). No such lesion exists. II. Mesenchymal Odontogenic Tumors A. Benign 1. Soft tissue a. Odontogenic Fibroma. b. Odontogenic Myxoma (Fibro-Myxoma).
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2. Hard tissue (with inductive changes) a . De n t i n o m a . b. True Cementoma (Benign Cementoblastoma). c. Periapical Cemental Dysplasia. d. Florid Cemento-Osseous Dysplasia (Gigantiform Cementoma). 3. Mixed (with inductive changes) Cementifying Fibroma. B. Malignant 1. Soft Odontogenic Fibrosarcoma 2 . Hard (with inductive changes) No such lesion exists. 3. Mixed (with inductive changes) No such lesion exists. III. Mixed Odontogenic Tumors A. Benign 1. Soft Ameloblastic Fibroma (FibroAmeloblastoma) 2 . Hard (with inductive changes) a. Compound Composite Odontome. b. Complex Composite Odontome. c. Dilated Odontome (Gestant Odontome; Dens In Dent). 3. Mixed (with inductive changes) a. Ameloblastic Fibro-Odontome. B. Malignant 1. Soft tissue Ameloblastic Fibrosarcoma 2. Hard tissue (with inductive changes) No such lesion exists.
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Fibroma Fibromyxoma
Lipoma
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7. Vascular Origin
Haemangioma
a.
b.
Haemangioma
Lymphangioma
a. b.
Liposarcoma
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Rhabdomyosarcoma Leiomyosarcom
8. Haemopoeitic and Lymphoreticular Plasma Cell Myeloma Hodgkin's Lymphoma Burkitt's Lymphoma
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I. Pericoronal radiolucencies
1. Dentigerous cyst. 2. Primordial cyst. 3. Calycifying odontogenic cyst. 4. Ameloblastoma. 5. Unicystic ameloblastoma. 6. Adenomatoid odontogenic tumors. 7. Ameloblastic fibroma. 1. Simple ameloblastoma This is a benign locally invasive, soft epithelial odontogenic neoplasm. Incidence
1.
Simple ameloblastoma may occur at any age, but it most It occurs most frequently in the mandible mainly in the molar-
r amu s a re a. Histogenesis Simple ameloblastoma may arise from any odontogenic epithelium. The sources of its epithelium are:
1.Basal 2. 3.
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Mallassez).
5.
Clinical Features
Painless swelling unless secondarily infected. No facial disfigurement is noticed except when the tumor attains a large size. The growth commonly expands both lateral and lingual aspects of the mandible. The tumor does not usually perforate the cortical bone. Even when this bone is perforated, the tumor does not break through the periosteum unless the surface is traumatized.
Pathological Features
Ameloblastomas may be solid, micro-cystic or may contain one or more large cystic The partitions between the large cysts contain bone. Cystic ameloblastomas contain a clear or slightly turbid albuminous fluid
spaces.
Large multilocular radiolucent area in the affected part of the jaw. Less commonly, unilocular radiolucent area.
Histopathological Features
bordered by cuboidal or tall columnar cells resembling those of the internalenamel epithelium.
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cellularity.
In this variant, the tumor epithelium takes the form of more or less
l o o s e l y intercommunicating cells resembling the stellate reticulum, surrounded by a layer of cuboidal or columnar cells resembling cells of the internal enamel epithelium or preameloblasts.
Cyst formation is common within the epithelial islands. In cases of cyst formation, the several histological patterns may be seen Cystic Ameloblastoma Acanthomatous type: the presence of squamous metaplasia and
keratin.
3. Keratoameloblastoma: In most ameloblastomas keratinization is
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pattern.
Plexiform
In this variant, the tumour epithelium is arranged in the form of irregular The epithelial strands, just like the follicles of follicular ameloblastoma,
are bounded by a layer of columnar or cuboidal cells surrounding loosely intercommunicating cells similar to those of the stellate reticulum.
three histological variants of unicystic ameloblastoma have been In the first, a cyst epithelial lining may exhibit transformation to
described:
1.
one with cuboidal or columnar basal cells with hyperchromatic nuclei and subepithelial hyalinization.
2.
In the second variant, the cyst lining is similar to that of the first,
with a localized nodule arising from part of the lining and projecting into the cyst lumen.
3.
ameloblastoma, is formed of typical follicular or plexiform ameloblastoma growing in and infiltrating part of the wall of a cyst producing a mural projection into the cyst cavity.
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As the tumor grows, it causes resorption of some of the bone in its vicinity. The tumor spread into neighboring cancellous spaces without resorption of the bone surrounding these spaces. The absence of capsule gives the tumor its locally invasive nature. The tumor invades cancellous spaces and does not invade the Haversian canals of compact bone. Therefore, in the compact bone of the lower border of the mandible, the clinical and radiographic limit of the tumor is likely to be the true limit.
2.
3. 4.
This is the treatment of choice in small, solid or multicystic A safety margin of about 1.5 cm of clinically uninvolved bone,
lesions.
all around the boundaries of the lesion should be included in the resection. 2. Segmental Resection
This is indicated with large tumors that have eroded the cortical bone and involved the periosteum and soft tissue. A safety margin of about 1.5 cm of clinically uninvolved bone, all around the boundaries of the lesion should be included in the resection.
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3. Curettage
This should not be used in the treatment of ameloblastoma because of the high risk of recurrence.
4. Radiotherapy
2. ADENOMATOID ODONTOGENIC TUMOR Origin: arise from the enamel organ or its remnants. Clinically
1. Symptomless, well-defined swelling of the affected area of the jaw. 2. It usually occurs in the maxillary second incisor-canine region.
with an unerupted t o o t h .
2. In most cases it appears like a dentigerous cyst but the
radiolucency appears to extend apically further than the cementenamel junction of the involved tooth. Treatment: enucleation or conservative surgical excision. 3. AMELOBLASTIC FIBROMA
1.
It is a benign mixed odontogenic tumor of soft tissues origin. lesion producing expansion of the affected area of the jaw.
3.
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4.
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7. Dentigerous cyst.
8.
Dentoalveolar abscess. Periapical granuloma. Chronic suppurative osteomylities. Cementoblastoma (osteolytic stage). Cemento-ossyfing fibromas (osteolytic stage). 1. Radicular cyst
9. 10.
11. 12.
Differential diagnosis 1. Well defined radiolucency + untreated asymptomatic teeth + non vital pulp Radicular cyst.
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2. Teeth with endodontic treatment + asymptomatic, non enlarging radiolucency at the apex Periapical scar. 3. Endodontic treated teeth + asymptomatic radiolucency after root resection surgical defect.
4. Periapical radiolucency in the mandibular premolar molar region + vital
tooth Traumatic bone cyst as radicular cyst is occurred more common in the anterior region.
2. Periapical scar
1. Is a dense fibrous tissues and is situated at the apex of a pulpless tooth in
whish the root canal have been successfully filled. 2. It represents a previous periapical granuloma, cyst, or abscess. 3. Surgical defect Is an area that fails to fill in with osseous tissue after surgery. 4. Periapical cemento-osseous dysplasia Clinical features
1.
T h i s i s a d y s p l a s t i c d e v e l o p m e n t a l disturbance of cementum. It occurs around the apex of a tooth, usually a lower incisor. The condition is usually asymptomatic.
2. 3.
Radiographic examination: the radiographic picture varies with its histologic structure and stage of development. Four stages of development are usually described:
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a. Osteolytic stage:
This is the earliest stage which represents the immature cementoma composed of cellular element with no calcification. There is bone destruction wh ich app ears rad iograph ical ly as r ad io luc en cy similar to a granuloma or a radicular cyst.
of radiopacity within the radiolucent lesion. d. Mature stage: With gradual and c o n t i n u e d f o r m a t i o n o f c e m e n t u m , calcification of the whole lesion is almost complete, with remnants of the formative tissue surrounding the lesion. The lesion now appears as an irregular area of radiopacity with a thin radiolucent border around it. Treatment : No treatment of this lesion is required Differential diagnosis (for the osteolytic stage)
1. Teeth with vital pulp + mainly in the mandibular incisor region + older
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5. Traumatic bone cyst Differential diagnosis The Traumatic bone cyst can be confused with median mandibular cyst but the median mandibular cyst causes a separation of the teeth while the Traumatic bone cyst does not.
6. Malignant tumors 1. Malignant tumor may appear as single periapical radiolucency as squamous cell carcinoma, chondosarcoma, fibrosarcoma. 2. Differential diagnosis is done by careful clinical examination and history of the lesion + Biopsy.
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to develop. 7. Odontome. Odontome Benign mixed odontogenic tumors of hard tissues origin. Three types of odontomes are identified:
1.
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spa ce , su rro un de d b y dentine, which is covered by enamel in its coronal part and may be covered by cementum in its radicular part) are seen.
2.
wh i c h t h e e n a m e l or gan becom es invaginating the dentine papilla, with the development of an enamel lined cavity within the dentine.
Clinically
1. 2.
Odontomes presenting themselves as local swellings. Odontomes are developmental malformations and are not The only danger encountered with these tumors is that they may attain
a large size. Thus weakening the jaw or even causing pathological fracture. Radiologically
1.
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Metastatic tumor to the jaws. 3. Others: 1- Central giant cell granuloma. 2- Giant cell lesion of hyperparathyroidism.
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1. Odontogenic Myxoma 1. 2. Origin: derived from odontogenic mesenchyme, this is a locally Clinical features :
invasive neoplasm It appears as slowly growing bony hard swelling of the asymptomatic Mandible > maxilla Female > male In dentated area it may extend interradicular areas
3.
with delicate or coarse trabeculations give the image of honeycomb or soap-bubble appearance. 4. 5. Histopathology : Stellate shaped cells in mucoid stroma No capsulation When the collagen fibers increased its called Myxofibroma Treatment: I. Surgical excision (local invasive & high recurrence)
1.
Enbloc Marginal resection Mainly for extensive, multilocular, ill-defined borders When > 1 cm of inferior border will be left after excision of lesion Segmental resection If less than 1 cm will be lift N.B.: Inferior alveolar nerve:
1.If
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resection
2.If
II. Reconstruction 6.
D.D from ameloblastoma is: The myxoma show fine trabeculation within the small lobules, Histopathology is the main way of differentiation.
Etiology: Intra-bony hemorrhage or inflammation. High recurrence rate. Common in young adults. Treatment:
1. 2.
Surgical resection. Recently calcitonine or interferon injection. 3. Gaint cell lesion of hyperparathyroidism
Characterized by
1. Increased 2. Increased 3. Multiple
lesions.
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4. Loss
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found within bone. It is more located in the mandible, than maxilla. 1. Clinically: Patient complains of spontaneous
gelfoam, steel coils and wisps of cotton, lyophilized dura and cyanacrylate. 3. Embolization should be followed with surgical removal of the
If the lesion is present in the posterior part of the mandible + If the lesion is present in the posterior part of the mandible +
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patient are over 30 years old + no parasethesia of the lip Multilocular cyst.
3.
are between 10 - 30 years old + pain and parasethesia of the lip are rare Odontogenic myxoma.
Malignant non odontogenic tumor. They are a group of lesions characterized by excessive plasma cell-like Clinically Pain and anemia are the commonest features. Pathological fracture and cervical lymph node involvement are
aggregations.
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less common. 4.
In multiple myeloma, the laboratory findings show: Ele va te d se ru m glob ul in lead in g to reversed Raised total serum proteins. Elevated erythrocyte sedimentation rate (ESR). Lymphocytosis and anemia of variable degrees. Bence-Jones protein in urine. Radiographically: Multiple myeloma shows punched out lesions of varying size Treatment: Multiple myeloma is treated by chemotherapy and it has a poor
5.
The multiple R.L lesion of MM are usually smaller and more numerous. Laboratory findings show el evat ed serum gl obul in l eadi ng t o
reversed albumin/globulin ratio (A: G ratio) and the presence of Bence-Jones protein in urine MM.
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Rapidly growing, firm swelling leading to facial deformity, with pain. Followed by loosening of related teeth, toothache, bleeding. In maxillary lesions nasal obstruction may follow. In mandibular lesions, paraesthesia of the lower lip is a
common finding. Radiographically: bone-producing lesion penetrates through the cortex, lifts up the periosteum producing the typical "sun-ray" appearance. Treatment: radical resection. D.D
1. Differential Diagnosis with Chondrosarcoma and chondroma:
Chondrosarcoma and chondroma affect mainly an older age patient and more often in the anterior maxilla.
2. Differential Diagnosis with Cementoossifying fibroma Cementoossifying fibroma appears as circular, well defined marginated, and not have the sunburst appearance. 2. CHONDROMA
1.
from incomplete absorption of Meckel's cartilage or in the symphysis from remnants of the accessory symphyseal cartilages.
2.
Clinically: It is slowly growing, painless, and usually appears as a Treatment: surgical excision. 3. CHONDROSARCOMA
1.
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2.
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3.
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1. Periapical cementoosseous dysplasia (intermediate stage). 1. D.D of PCOD with Osteoblastic carcinoma, chondosarcoma, and osteogenic sarcoma:
Slowly growing tumors + smooth, well defined fibroosseus lesion PCOD. Rapidly growing tumors + irregular, ill defined fibroosseus lesion Osteoblastic carcinoma, chondosarcoma, and osteogenic sarcoma.
Odontome is usually located above the crown of unerupted tooth, sometimes between the teeth and rarely in the periapices.
3. D.D of PCOD with Cementoossifying fibroma: It is a difficult differentiation because the two lesions occur at the apex of a vital tooth + they are round with well defined border.
The differentiation between them is very important because cementoossifying fibroma need excision while the PCOD need only removal.
PCOD Common lesion occur mainly in the lower incisors region Female > male occur in patient over 30 years old rarely to attain a diameter of more than 1 cm rarely produce mandibular expansion multiple lesion
cementoossifying fibroma uncommon lesion occur mainly in the lower premolar molar region male > female occur in patient under 30 years old frequently attain a diameter of more than 1 cm frequently produce mandibular expansion single lesion
2. Cementoossifying fibroma
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1. 2.
Benign mesenchymal tumor (Mixed tissues) Clinical features: It presents itself as a painless swelling usually in Radiographically : radiolucent area which g r a d u a l l y b e c o m e s Treatment: surgical excision.
3. AMELOBLASTIC FIBRO-ODONTOME 1. Benign mixed odontogenic tumor. 2. This is a rare neoplasm having the histological features of ameloblastic fibroma but showing inductive changes leading to the formation of hard dental tissues (enamel and dentine). 3. Radiographically: it is characterized by the presence of multiple small radiopaque masses in a radiolucent lesion. 4. Generally this tumor behaves as ameloblastoma and should be similarly managed. 4. CALCIFYING EPITHELIAL ODONTOGENIC TUMOR (Pindborg's Tumor)
1.
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epithelial structures that calcify and become extruded into the surrounding stroma.
2.
Clinical features: slowly growing, painless swelling, often in the area of a non-erupted tooth. Radiographic features: m u l t i l o c u l a r r a d i o l u c e n c y c o n t a i n i n g r a d i o p a q u e a r e a s related to the crown of the associated unerupted tooth. The treatment: wide surgical excision.
3.
4.
Differential Diagnosis of pericoronal Mixed radiolucent radiopaque lesion associated with teeth Age Odontome First & second complex decade of life Jaws Mandible > maxilla Region Molar region Additional features
Anterior region
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Anterior region On aspiration, it gives a thick, granular, yellow fluid (Keratin) while the aspiration of odontome is unproductive. 52 % associated with
75 % occur COC 47 % occur in patient under 31 years old Mandible > maxilla anterior to the first molar
unerupted tooth & does not often produce large, dense masses of calcified tissues.
79940460.doc 91 8. Ewing's sarcoma. 9. Burkitt's lymphomas. 10. Chronic alveolar abscess. 11. Chronic osteomylities. 12. Osteoradionecrosis.
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Age: Usually above middle age between 50-70 years, but in Egypt it
Sex: Males are more commonly affected that females in about 3:1 ratio.
2. Etiology The etiology of Sq C.Ca is unknown, but the following risk factors may be considered as predisposing factors:
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A. Tobacco abuse. B. Alcohol abuse or heavy use. C. Combined risk of heavy alcohol and tobacco use. D. Viral infection (HSV, HPV). E. Sunlight exposure. F. Poor condition of the dentition. a. Sharp edges of carious teeth. b. Sharp denture clasps. G. Betel leaf chewing especially in Indian and Tobacco chewing in the Sudan. H. Syphilis. I. Malnutrition a. Iron deficiency anemia (Plummer Vinson syndrome). b. Hypovitaminosis: Vitamins A and B complex.
3. Diagnosis Diagnostic Clinical Features: Relatively chronic history. Indurated margin of the ulcer. Resistant to improvement by local treatment. Presence of enlarged stony hard cervical lymph nodes. Special Investigations to Confirm the Diagnosis 1. Biopsy: This is the most important investigation 2. X-ray: This is of little importance as the lesion is mainly a soft tissue
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lesion. 4. PRE-CANCEROUS LESIONS IN THE ORAL CAVITY (Reading) 1. Leukoplakia: this means a white patch. The buccal mucosa is the most commonly affected part. 2. Erythroplakia: means red patch, red plaques or well defined red patches with tiny areas of ulcerations. 3. Tr aum at ic de nt al u lc er s: May occur anywhere on the oral mucosa usually against sharp edges of broken teeth. 4. Erosive lichen planus: The common sites are the cheek and lateral border of the tongue. Solitary or multiple lesions appear as superficial ulcers surrounded by white lines or plaque.
5. Histopathology 1.Carcinoma in situ: Non-invasive carcinoma is a lesion in which the whole thickness of epithelium shows histologic and cytologic features of epithelial dysplasia, but the basement membrane is intact and there is no invasion of the underlying connective tissue. 2.Invasive carcinoma: When strands and islands of dysplastic epithelial cells break through the basement membrane and invade the underlying connective tissue. 6. Subdivision of Sq C Ca: Degree of differentiation:
1.
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moderate degree of differentiation as evidenced by some areas of cell nests and epithelial pearls.
3.
Poorly Differentiated: the tumor shows very few or no cell nests and
Local spread: The lesion increases in size by direct local infiltration Lymphatic spread. Blood borne metastasis: Is rare and late in the course of the disease.
the neck indicating that metastatic spread to cervical lymph nodes has already occurred.
2.The patient may first notice a white spot, a sore or swelling in the mouth.
Late:
1. P ai n du e to sec on da ry inf ecti on or involvement of nerves in the
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region.
2. Excessive salivation which may be blood stained. 3. Dysphagia. 4. Ankyloglossia in case of cancer tongue and floor of the mouth. 5. Deviation of the tip of the tongue towards the affected side on protrusion.
9. Clinical appearance Carcinoma may take the form of: a. An ulcer: It is the most common type; it is characterized by being hard with indurated base and raised everted edges. a. b. A nodule: Usually hard below the mucosa without signs and A chronic fissure: usually on top of leukoplakia, not responding symptoms of acute infection. to treatment; ulceration may occur in the fissure. b. Papillary form: Appears as a soft warty growth that may be extensive. e. Atrophic mass: It produces a small hard mass.
Exophytic "Cauliflower-like or papillary": It grows slowly on the surface to the outside with minimal invasion or infiltration of underlying tissues. It metastasizes late in its course to the regional lymph nodes. Prognosis is good. Endophytic "Ulcerative or infiltrative": It grows rapidly and rapidly infiltrates the underlying tissues. Rapid metastasis to lymph nodes, prognosis is poor.
2.
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Verrucous: It is markedly exophytic and shows a low degree of malignancy. It affects just the surface mucosa. It erodes rather than invades the underlying tissues. It does not metastasize to lymph nodes, prognosis is excellent.
Lips: the vermilion border and labial mucosa. The vermilion border of the
lower lip is more commonly affected than the upper lip as it is more exposed to the ultraviolet rays of the sun. 2.
3.
Buccal Mucosa Gums "Gingiva and Alveolar Mucosa": this usually occurs in the premolar Tongue: It is the most commonly affected site with squamous cell carcinoma in
the oral cavity. T h e i m p o r t a n t s y m p t o m i s persistent dysphagia and sore throat. Neoplastic involvement of the lingual nerve or nerves is responsible for the pain referred to the ear on the affected side in case of cancer tongue or floor of the mouth.
5.
midline lateral to or involving the frenum. The first symptom is sometimes an induration that is felt with the tip of the tongue.
6. 7.
Palate: Relatively rare. It is a disease of elderly men. Retromolar Region: It is the most serious site as it is hidden and usually
diagnosed at a later stage. It spreads to the pharynx, cheek, mandible and maxilla. It may cause trismus due to invasion of muscles of mastication. 12. Treatment of Oral Carcinoma: In the end of the chapter.
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Rapidly growing, firm swelling leading to facial deformity, with pain. Followed by loosening of related teeth, toothache, bleeding. In maxillary lesions nasal obstruction may follow. In mandibular lesions, paraesthesia of the lower lip is a
common finding. Radiographically: bone-producing lesion penetrates through the cortex, lifts up the periosteum producing the typical "sun-ray" appearance. Treatment: radical resection. 3. CHONDROSARCOMA Clinically
T r e a t m e n t : r a d i c a l su r g i c al resection. 4. FIBROSARCOMA Clinically : Pain, swelling and disfigurement of the face are the usual symptoms. Treatment: radical surgical excision. Differential diagnosis of solitary radiolucemcies with ragged and poorly defined borders
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1. The D.D of this lesion is very difficult as the clinical features of the entire lesion are the same. 2. For that the D.D depend mainly on the patient age and the location of the lesion and some additional features. 3. Patients age: SCC occur in older patients. Chondrsarcoma and OS occur in young patients. 4. Location of the lesion: SCC and OS occur in the mandible more than the maxilla.
5. Additional features: If the patient had a history of tobacco smoking and alcohol consumption + rapid growth swelling SCC.
3. Primordial cyst.
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4. Odontogenic keratocyst. 5. Unicystic ameloblastoma. 6. Giant cell lesion. 7. Focal cementoosseous dysplasia. 8. Incisive canal cyst. 9. Midpalatine cyst. 10.Ossifying fibroma. 11.Benign non odontogenic tumors. 1. Odontogenic keratocyst Differential diagnosis 1.Should be differentiated from: Residual cyst, Traumatic bone cyst and Primordial cyst.
2.By aspiration:
Cheesy, thick and yellow material Odontogenic keratocyst. Air or non productive aspiration Traumatic bone cyst. 3. By presence or absence of the tooth: If the tooth fail to develop Primordial cyst. If the tooth was extracted and the cyst was associated with it Residual cyst. 2. Giant cell lesion (Osteoclastoma) 1. 2. Malignant non odontogenic tumors. The skeletal location of giant cell tumor is similar to that of
osteogenic sarcoma; 50% of cases occur near the knee or the upper end of the tibia. True giant cell tumors of the jaws are rather rare.
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3.
Radiographically: large, oval, radiolucent lesion. 3. Focal cementoosseous dysplasia 1. Asymptomatic, focal, and radiolucent in the early lesion, radiopaque in the mature lesion, or mixed radiolucent-radiopaque with well to poorly defined border. 4. Incisive canal cyst and Midpalatine cyst.
Differential diagnosis 1. Should be differentiated from: mucoepidermoid tumor (low grade) and lipoma. 2. For mucoepidermoid tumor (low grade):
Occur mainly in the lateral aspect of the palate near the anterior palatine foramen.
On aspiration give viscous, clear, sticky fluid not an amber colored fluid. 4. For lipoma: differentiated from cyst by aspiration. 5. Incisive canal cyst can be easily differentiated from midpalatine cyst Incisive present in the canal above the palatine papillae while midpalatine cyst present in the midline of the palate posterior to the papillae. 5. Ossifying fibroma 1. It is a true benign non odontogenic neoplasm of skeletal fibrous ti ssue . 2. Clinically: slow growing tumor that causes early displacement of the teeth involves in the region.
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3. Radiographically: the lesion appears as an a r e a o f r a d i o l u c e n c y s p e c k l e d w i t h radiopacities. 4. Treatment: surgical excision. 5. Differential diagnosis: from periapical and focal cementoosseous dysplasia in that it occur in younger patients, most often in the premolar molar region of the mandible. 6. Benign non odontogenic tumors 1. Benign non odontogenic tumors are rarely observed within the jaws 2. As examples: lipoma, salivary gland adenoma, amputation neuroma, neurofibroma, neurilemmoma (shwannoma), leiomyoma, rhabomyoma, fibroma, and myxoma. 3. Because their growth is slow, they appear as well defined radiolucency of varying shape. I. LIPOMA
1. This is a neoplasm of adipose tissue. 2. Clinically: it presents as a soft, smooth, rounded or lobulated
mass.
3. Treatment: surgical excision.
II. TRAUMATIC OR AMPUTATION NEUROMA 1. It is common in the region of the mental foramen. 2. The lesion is n o t a tr u e n eop l asm an d ap p ears as a b u l b o u s e n l a r g e m e n t a t t h e e n d o f traumatized nerves.
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3. Treatment: surgical removal. III. NEUROFIBROMA 1. This is a tumor of nerve sheath origin. 2. Clinically: It is a painless mandibular swelling together with skin and subcutaneous manifestations of multiple neurofibromatosis (von Reklinghausen's d i s e a s e of t h e s k i n ) . 3. Treatment: surgical excision. IV. NEURILEMMOMA 1. It is a benign tumor that arises from the sheath of nerve endings and most probably from the Schwann cells of the nerve sheath. 2. Clinically: round, ovoid or fusiform swellings. 3. Treatment: surgical excision. V. LEIOMYOMA 1. These are tumors of smooth muscle. 2. They are very rare tumors in the oral cavity. When they occur in the oral cavity, they usually occur in the tongue, where they may arise from the smooth muscle coats of blood vessels. 3. Treatment: surgical excision. VI. RHABOMYOMA 1. These are tumors of striated muscle. 2. They too are very rare in the oral cavity, and they also occur most commonly in the tongue.
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Central fibroma is a rare lesion, occurs in the mandible more than the maxilla. It could be of odontogenic or nonodontogenic origin. Clinically: It is a well-circumscribed pedunculated or sessile slowly growing lesions covered by smooth normal epithelium. Treatment: surgical excision. VIII. FIBROMYXOMA
2.
3.
exhibit a honey-comb appearance in a few areas and may be mistaken for an ameloblastoma.
4. Treatment: surgical excision with a good safety margin to avoid
recurrence.
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2.
Neurofibrosarcoma 3. Chondrosarcoma
4. Osteogenic Sarcoma 5. Giant Cell Tumor
6. 7.
8. Plasma Cell Myeloma 9. Burkitt's Lymphoma 10. Hodgkin's Lymphoma 11. Kaposi's Sarcoma NEUROFIBROSARCOMA
fibrosarcoma.
GIANT CELL TUMOR (Osteoclastoma) 1. 2. The skeletal location of giant cell tumor is similar to that of Radiographically: large, eccentric, oval, radiolucent destructive
osteogenic sarcoma. True giant cell tumors of the jaws are rather rare. lesion, producing cortical erosion and thinning, and expanding the bone contours. RHABDOMYOSARCOMA
1.
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years of age. It has the characteristics of rapid growth with nodal and lung metastases.
2.
It is a highly destructive lesion. Marrow endothelial cells or undifferentiated cells of t h e r e t i c u l o Jaw involvement is usually a part of a generalized disease. Clinically: The mandible is more affected than the maxilla. Intermittent pain and rapidly growing swelling. Low grade fever, malaise and leucocytosis are not uncommon. R a d i o g r a p h i c a l l y : i r r e g u l a r b o n e destruction is seen; there is
u se d .
BURKITT'S LYMPHOMA
1.
It is a lesion that differs from other malignancies in several ways: Its occurrence is linked to a viral exposure (Epstein Barr
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virus EBV).
It is associated with a chromosomal abnormality. It is considered the fastest growing human malignancy. Immunologically, the tumor appears to be of B-cell origin The tumor has two epidemiologic patterns, namely endemic and Clinically: Endemic Burkitt's lymphoma is a pediatric disease occurring
nonendemic forms.
2.
in patients between 6-9 years of age. The most common site of presentation is the face with the mandible being primarily affected by a rapidly growing destructive bony lesion causing loosening of the teeth. U s u a l l y t h e r e i s n o a s s o c i a t e d lymphadenopathy.
Nonendemic form: the most common site of presentation is the Radiographically: small areas of bone resorption are seen as an
abdomen with the head and neck region affected in about 5% of the cases.
3.
early sign and they later coalesce to form larger areas of bone destruction.
4.
Treatment: Chemotherapy.
NON-HODGKIN'S LYMPHOMA
1.
ramus area of the mandible. Loosening of teeth is common and may be an early manifestation.
2.
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1.
the oral cavity and many visceral organs. They appear as reddish or brownish red nodules which vary in size and are usually tender or painful.
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5. Cemento-osseous dysplasia. Periapical cemental dysplasia. Focal cemento-osseoua dysplasia. Florid cemento-osseoua dysplasia. Ossifying fibroma 1. It is a true benign non odontogenic neoplasm of skeletal fibrous ti ssue . 2. Clinically: slow growing tumor that causes early displacement of the teeth involves in the region. It causes varying degrees of facial deformity which is usually the main complaint of these patients. 3. Radiographically: the lesion appears as an a r e a o f r a d i o l u c e n c y s p e c k l e d w i t h radiopacities of varying densities depending on the degree of calcification present. 4. Treatment: surgical excision.
BENIGN OSTEOBLASTOMA 1. It is a benign non odontogenic neoplasm. 2. Clinically: The lesion is usually central and pain and swelling of relatively short duration are the main features.
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3. Radiographically: it is a well defined radiolucency with some evidence of new bone formation. 4. Treatment: surgical excision. OSTEOMA
1. It is a benign non odontogenic neoplasm. 2. It could be peripheral (periosteal) or central ( endost eal ) and m ay be
multiple.
3. Radiographically: it appears as well defined radiopacities. 4. Treatment: surgical excision.
Benign mesenchymal odontogenic tumors. T h i s i s a d y s p l a s t i c d e v e l o p m e n t a l disturbance of cementum. It occurs around the apex of a tooth, usually a lower incisor. The condition is usually asymptomatic.
6. 7.
Radiographic examination: the radiographic picture varies with its histologic structure and stage of development.
This is the earliest stage which represents the immature cementoma composed of a cellular element with no calcification.
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There is bone destruction wh ich app ears rad iograph ical ly as r ad io luc en cy similar to a granuloma or a radicular cyst.
gradual and c o n t i n u e d f o r m a t i o n o f c e m e n t u m ,
calcification of the whole lesion is almost complete, with remnants of the formative tissue surrounding the lesion.
The
with a thin radiolucent border around it. Treatment: No treatment of this lesion is required.
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1. 2.
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c ha ra ct er iz ed by mult ip le, lob ul ated, bilaterally symmetrical lesions in several parts of the jaws.
3.
These are developmental non-neoplastic outgrowths appearing around the midline of the palate (torus palatinus) more frequently than the lingual surface of the mandible (torus mandibularis). Tre at me nt: if ne ce ssar y for pr osthet ic purposes, is excision.
2.
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1. Papilloma 2. Pyogenic granuloma 3. Pregnancy tumors 4. Peripheral giant cell granuloma 5. lipoma 6. Hemangioma
Pyogenic granuloma
Benign non odontogenic tumor. This is a benign neoplasm of skin and mucous membrane. Clinically: the lesion appears as a sessile or pedunculated cauliflowerlike raised lesion which may or may not be keratinized Treatment: surgical excision.
4.
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Cause: increase in estrogen and progesterone during pregnancy and nutritional deficiency and poor oral hygiene are responsible for this condition.
Clinically: The color of the tumors is deep red to purple whish fades on compression; after delivery, it may regress partially or completely disappear.
Treatment: Surgical excision by electrosurgery is recommended without removal of the adjacent teeth.
Nature: This lesion derives its name from the histological finding of
Clinically It occurs only on attached gingiva. The premolars and molars region in the a n d i b l e is th e fa v o r e d m
1. 2.
of irritation or trauma. 4. The lesion can erode the underlying alveolar bone and often induces a cup-
adjacent teeth). The base of the tumor should be cauterized after surgery.
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1.
Application of pressure will cause blanching of the lesion. 2. The capillary type has small endothelial-lined vessels. It occurs in the
mouth and face to be known as port-wine stain. 3. The cavernous type has large endothelial-lined vessels with tendency to
Treatment 1. 2. Surgical excision after ligation of the main feeding For high flow or large lesions, selective embolization vessels which determined by angiograms (arteriography). by striated muscles or silicone pellets to occlude the feeding vessels. 3. Injection of sclerosing solution such as 1% sodium
tetradecyl sulfate (sotradecol) or sodium morrhuate to provoke inflammatory response with subsequent fibrosis and obliteration of vascular channels. 4. 5. Cryotherapy is indicated for small to moderate sized Radiotherapy may be used in large hemangiomas to superficial lesion especially in poor risk patients. produce sclerosis of the feeding vessels and fibrosis of the tumor. Excision, then, can be made with elecroscalpel. 6. Co2 or Nd: YAG laser can be used successfully for its ability to penetrate soft tissues to 1-cm depth resulting in deep photocoagulation.
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mass.
4. Treatment: surgical excision.
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FIBROMA
1. 2.
Benign non odontogenic tumor. Central fibroma is a rare lesion, occurs in the mandible more than the maxilla. It could be of odontogenic or nonodontogenic origin. Clinically: It is a well-circumscribed pedunculated or sessile slowly growing lesions covered by smooth normal epithelium. Treatment: surgical excision. SQUAMOUS CELL PAPILLOMA
3.
4.
5. 6. 7.
Benign non odontogenic tumor. This is a benign neoplasm of skin and mucous membrane. Clinically: the lesion appears as a sessile or pedunculated cauliflowerlike raised lesion which may or may not be keratinized Treatment: surgical excision. HAEMANGIOMA
8.
1. Benign non odontogenic tumor. 2. Clinically: Solitary, multiple or diffuse lesions may occur, and the lesion may occur centrally within bone. Central lesions are slowly growing, and pulsations may be elicited over the tumor. 3. Radiographically: central haemangiomas present as multilocular circumscribed honeycomb radiolucencies. 4. Treatment: surgical excision after tying of the feeding vessels. Cryosurgery has also been advocated.
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LYMPHANGIOMA 1. Benign non odontogenic tumor. 2. This is similar to haemangioma both clinically and radiographically. 3. They are commonly occurring in the tongue leading to macroglossia. 4. Clinically: Superficially located lesions appear papillary and of the same color or slightly more reddish than the surrounding mucosa; deeper lesions appear a s d i f f u se n od u l es wi t h n o s i g n i f i c a n t difference in surface color or texture. 5. Treatment: surgical excision after tying of the feeding vessels. Cryosurgery has also been advocated.
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Rhabomyosarcoma. Neurofibrosarcoma.
III. Cyst 1. Thyroglossal duct cyst. 2. Demoid & epidermoid cyst. 3. Mucous extravasation or retention cyst.
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III. Salivary gland 1. Benign tumors: Plemorphic adenoma. Basal cell adenoma. 2. Malignant tumors: Adenocystic carcinoma. Mucoepidermoid carcinoma. IV. Cyst 1. Non odontogenic fissural cyst: Nosopalatine cyst. Median palatine cyst. Globlomaxillary cyst. 2. Odontogenic cyst enlarge to expand palatal bone: Keratocyst. Dentigerous cyst. Inflammatory developemental cyst. V. Benign odontogenic tumors causes expansion palataly 1. Epithelial in origin:
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Ameloblastoma. Adenomatoid odontogenic tumors. Calcifying epithelial odontogenic tumors. Squamous odontogenic tumors.
2. Mesenchymal in origin: Odontogenic fiboma. Odontogenic myxoma. 3. Mixed: Ameloblastic fibroma. SQUAMOUS ODONTOGENIC TUMOR
1.
Clinical features: slowly growing, painless swelling of small size and loose teeth. Radiographically: it appears as radiolucent lesion related to the roots of the teeth and sometimes associated with an impacted tooth. Treatment: conservative surgical excision. ODONTOGENIC FIBROMA
2.
3.
1.
This is a benign fibrous neoplasm with islands of entrapped inactive Radiographically: i t u s u a l l y a p p e a r s a s a u n i l o c u l a r Treatment: is by wide surgical excision. There is little tendency to
radiolucency.
3.
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It is a slowly growing, painless, lesion producing expansion of the affected area of the jaw. Radiographically: it appears as a well defined radiolucent area with a regular outline. Treatment: surgical excision. VI. Malignants odontogenic tumors causes expansion palataly
2.
3.
1. Epithelial in origin: Malignant Ameloblastoma. Ameloblastic carcinoma. 2. Mesenchymal in origin: Ameloblastic fibrosarcoma MALIGNANT AMELOBLASTOMA 1. Clinical features : It presents itself as a painful swelling of rapid progression. 2. Radiographicaly: appears as an irregularly outlined radiolucent area with manifestations of bone destruction. AMELOBLASTIC CARCINOMA 1. In these cases a squamous cell carcinoma may have arisen from areas of squamous metaplasia in a pre-existing ameloblastoma. AMELOBLASTIC FIBROSARCOMA (Ameloblastic Sarcoma)
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It is similar to ameloblastic fibroma in which the mesodermal component shows malignant features of a sarcoma.
History of the lesion Clinical examination Diagnostic aids(biopsy & imaging) Decision making & treatment planning Reconstruction and rehabilitation and psychotherapy
III. Lines of treatment 1. Surgery: (TWO PHASE) PHASE I This includes excision of the tumor with safety margins of 1-3 cm of
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adjacent normal tissues and radical neck dissection of the lymph nodes. PHASE II Reconstruction and rehabilitation of either soft tissue or bone or both 2. Neck dissection.
3. Radiotherapy .
lesions, especially if it is inaccessible sites. Also it is used post surgical to kill any residual tumor cells at the margins of excision. 4. Chemotherapy.
Its chief role in treatment is palliative. Effect: kill malignant cell and stop their metabolism. Side effect: affect normal body cells To decrease side effect: 1. 2. their toxicity Injection into the artery feeding the tumor Use multiple chemical agents to decrease
surgery increase the long-term efficacy of surgery alone in certain cases. These combinations still remain the most effective means of
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vigorous scraping. 2. After the gross lesion is removed a margin of normal bone should be
removed using a scraping motion with large round surgical bur. 3. recurrence. Uses 1. This technique is used successfully for benign encapsulated tumors The bony bed of the tumor can be treated with cryotherapy,
electrocautery or chemical cautery to kill remnants of the tumor cells and reduce
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with no tendency of recurrence. For example it may be used for odontoma, ameloblastic fibroma, and ossifying fibroma. 2. It is used successfully also for oral benign soft tissue lesions such as
fibromas, pyogenic granuloma, peripheral giant cell granuloma and papilloma Curettage: Scrapping of bone after excision of the lesion to remove any remnants
2- Enbloc marginal resection (Block excision) Technique 1. This is a surgical procedure in which the entire tumor is removed intact with a rim (1 cm) of the surrounding uninvolved bone without disruption of the continuity of the jaw. Uses 1. It is frequently advocated for the treatment of
aggressive odontogenic tumors (e.g, ameloblastoma) when there is at least 1 cm of uninvolved bone closer to the inferior border of the mandible. 2. It is either done through inraoral or extraoral approaches.
The intraoral approach is used with lesions affecting the tooth-bearing portion while the extraoral approach is used with lesions of the ramus or when immediate reconstruction is planned.
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3- Segmental resection Technique 1. In this technique the lesion is removed with 1-2 cm of uninvolved bone distal and proximal to it with continuity defect or disruption of the jaw including inferior border of the mandible. Uses 1. myxoma. 2. Either partial (hemimandiblelloectomy) or total (full It is indicated in large aggressive tumor with less than 1 cm
mandiblelloectomy).
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4- Composite resection Technique 1. I t i s t h e r e s e c t i o n o f t u m o r w i t h t h e i n v o l v e d j a w (Hemimandibulectomy or hemimaxillectomy) and adjacent soft tissues and regional lymph nodes. Uses
1.
It's block excision via I.O incision only. G.A. Intra-oral incision extends 1 cm beyond the lesion is performed. Bone is cut using surgical bur not reaching inferior border of the
mandible.
5.
Bone block and overlying soft tissue are removed as one segment.
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Suturing.
mandible.
5. Intermaxillary fixation is performed to fix mandibular position. 6. E.O submandibular incision. 7. Dissection of soft tissue, legation and cut the facial artery. 8. Complete bony cuts at inferior border of the mandible. 9. Bone block and overlying soft tissue are removed as one segment. 10. Suturing both I.O and E.O. in layers.
Technique
Delayed reconstruction 1 stage: Resection and reconstruction plate 2nd stage after 6 months bone reconstruction is done
st
Immediate reconstruction Tumor resection + reconstruction plate + grafting are done in the same surgery one stage surgery
Advantages
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radiographically to ensure absence of recurrence. Disadvantages * risk of infection need 2nd surgery * Any recurrence removal of the graft * risk of infection
Neck Dissection
Management of cervical lymph nodes after surgical TTT of the 1ry malignant tumors According to staging: I) Stage I & II:
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methods).
We have to perform Supra-Omo-Hyoid neck dissection (as the diagnosis may be false).
2) Stage III:
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the mandible to the clavicle and from the lateral border of the sternomastoid, sternohyoid, hyoid bone and contralateral anterior belly of djgastric medially till the anterior border of the trapezious. 3.
Muscles:
Platysma, anterior and posterior belly of digastric. Sternomastoid. Omohyoid, stylo-hyoid and part of trapezious.
Glands:
Internal jugular.
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classified it into 3 types: 2. Type I: preservation of spinal accessory nerve. 3. Type II: preservation of spinal accessory + sternomastoid.
4. Type III: preservation of spinal accessory + sternomastoid + internal
jugular vein.
5. Advantages:
* Avoid dropping shoulder after removal of spinal accessory nerve which supplies trapezious. * Avoid de-innervations atrophy of sternomastoid if preserved.
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5 ) S t a g e V:
Radiotherapy
Source of radiation. 1. Teletherapy: from machine to target e.g.: gamma ray or X- ray. Used for treatment of 1ry tumor, postoperative radiation and can't used in inaccessible area. 2. Brachytherapy (interstitial therapy): by injection of radioactive source inside
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the target e.g. Radium. Used in inaccessible area as the base of the tongue. Indication of Radiotherapy
1. Curative treatment: in radiosensitive lesions (O 2 content)
d. Patient with history of apnea with G.A. 2. Combined with surgery: In stage I, II, III and IV
Either before surgery debulking of tumor. After surgery to ensure damage of any cancer cells left
behind at the surgical site and in lymph nodes. 3. Palliative treatment: in stage IV with metastasis desensitization of ulcer. Contraindications: Pregnancy. Children not to affect bone growth.
Indirect effects: As radiotherapy ionization of H2O molecules inside the cells Free radicals destroy cells and DNA. Direct effects: by effect directly on tumor cells thermal damage & DNA damage.
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Radio sensitive: as lymphoma. Radio responsive (intermediate): as squamous cell carcinoma. Radio, resistant: as bony tumors due to J, 02 level. Skin burns and mucositis. ms fibrosis S.G atrophy and xerostomia. Rampant caries.
Post-irradiation care: Proper oral hygiene. Topical fluoride application to avoid radiation caries.
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Tendency for recurrence. Malignant transformation e.g. polymorphic adenoma, leukoplakia. 3. Site of the tumor.
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Management
L.A or field block. Surgical excision of the lesion with L.A or field block. Surgical excision of the lesion. Pack the palate with iodoform or vaselinized
gauze supported figure of 8 suture or clear acrylic p a l a t a l s t e n t . safety margin 5mm-10mm.
Examples
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Proper scaling,
Chlorhexidin with M.W and periotherapy L.A. Surgical excision. Tooth should be extracted Alveolotomy for adjacent bone. Curettage cauterization. Packing healing by 2ry intension.
Surgical excision.
Management
Packing
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Central fibroma L.A Surgical flap. Bone removal. Grasp the lesion by Allis forceps and complete surgical excision of the lesion. suturing
CGCG L.A Surgical flap. Bone removal. Enucleation of the lesion. Curettage of the lesion using bone curette to remove any remnant. Cauterization. suturing
Management
Ameloblastorna, myxoma small size Block excision (I.O): Excision with 1 cm safety margin. Marginal resection: 1. Excision of the lesion while leaving inf. Border of the md. Intact. 2. Technique: oI.O incision. o Excision with safety margin of bone and overlying mucosa. o Suturing. Large size Block excision (E.O + I.O) Segmental resection, hemimandibulectomy or hemimaxillectomy. Resection: I.O + E.0 incisions are done. F ollow ed by recons truction a. Delayed. b. Immediate.
Management
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may range from loss of alveolar bone to loss of major portions of the jaw.
2. Frequently,
the alveolus. In these cases the patient need ridge augmentation. This augmentation can be in the form of bone grafts, synthetic bone grafts, or a combination of these materials.
3. Defects
soft tissues of the buccal mucosa and palate. While very large defects or defects in patients who are poor surgical risks may require prosthetic obliteration in which a partial or complete denture extends into the maxillary sinus or nasal cavities.
4. In
The delay in reconstruction after the surgical removal of a malignancy is performed for several reasons:
Radiation whish used after surgery may affect the survival of bone
grafts.
The soft tissue deficits result after removal of the malignancy requires
given to maintaining the residual mandibular fragments in their normal anatomic relationship with intermaxillary fixation, external pin fixation, splints or internal fixation.